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Tai Chi and Postural Stability in Patients with Parkinson's Disease

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Patients with Parkinson's disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective. We conducted a randomized, controlled trial to determine whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinson's disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls. The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed. Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00611481.).
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Tai Chi and Postural Stability in Patients with Parkinson's
Disease
Fuzhong Li, Ph.D., Peter Harmer, Ph.D., M.P.H., Kathleen Fitzgerald, M.D., Elizabeth
Eckstrom, M.D., M.P.H., Ronald Stock, M.D., Johnny Galver, P.T., Gianni Maddalozzo,
Ph.D., and Sara S. Batya, M.D.
Oregon Research Institute (F.L.), the Oregon Medical Group (K.F.), and the PeaceHealth Medical
Group-Oregon (R.S.) — all in Eugene; Willamette University (P.H.) and BPM Physical Therapy
Center (J.G.) — both in Salem, OR; Oregon Health and Science University, Portland (E.E.);
Oregon State University, Corvallis (G.M.); and Oregon Neurology Associ ates, Springfield
(S.S.B.)
Abstract
Background—Patients with Parkinson's disease have substantially impaired balance, leading to
diminished functional ability and an increased risk of falling. Although exercise is routinely
encouraged by health care providers, few programs have been proven effective.
Methods—We conducted a randomized, controlled trial to determine whether a tailored tai chi
program could improve postural control in patients with idiopathic Parkinson's disease. We
randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale
(which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three
groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise
sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the
limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary
outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go
tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls.
Results—The tai chi group performed consistently better than the resistance-training and
stretching groups in maximum excursion (between-group difference in the change from baseline,
5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points;
95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI,
3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group
also performed better than the stretching group in all secondary outcomes and outperformed the
resistance-training group in stride length and functional reach. Tai chi lowered the incidence of
falls as compared with stretching but not as compared with resistance training. The effects of tai
chi training were maintained at 3 months after the intervention. No serious adverse events were
observed.
Conclusions—Tai chi training appears to reduce balance impairments in patients with mild-to-
moderate Parkinson's disease, with additional benefits of improved functional capacity and
reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke;
ClinicalTrials.gov number, NCT00611481.)
Copyright © 2012 Massachusetts Medical Society
Address reprint requests to Dr. Li at the Oregon Research Institute, 1715 Franklin Blvd., Eugene, OR 97403, or at fuzhongl@ori.org..
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
No potential conflict of interest relevant to this article was reported.
NIH Public Access
Author Manuscript
N Engl J Med. Author manuscript; available in PMC 2012 August 9.
Published in final edited form as:
N Engl J Med
. 2012 February 9; 366(6): 511–519. doi:10.1056/NEJMoa1107911.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
MOVEMENT IMPAIRMENTS, ESPECIALLY loss of the ability to maintain standing balance, adversely affect
function and quality of life in patients with Parkinson's disease.1,2 With progression of the
disease, patients lose postural stability and have gait dysfunction, difficulty managing
activities of daily living, and frequent falls.3,4 Although some motor dysfunction, such as
tremor, may be alleviated with drug therapy, characteristics such as postural instability are
less responsive to medication and require alternative approaches.5,6
Exercise is an integral part of the management of Parkinson's disease because physical
activity has been shown to retard the deterioration of motor functions and to prolong
functional independence.7–9 Resistance-based exercises that address deficits in balance and
strength have shown positive effects.10–12 However, they require safety monitoring and are
equipment-dependent. Research on alternative forms of exercise that could improve balance,
gait, and function in patients with Parkinson's disease is scarce.
Tai chi, a balance-based exercise, has been shown to improve strength, balance, and physical
function and to prevent falls in older adults.13–15 Two pilot studies suggest that it may also
improve axial symptoms of Parkinson's disease, such as postural stability.16,17 However,
there exist few data from large-scale randomized trials that have addressed the efficacy of tai
chi in this context.
The primary aim of this study was to examine whether a tailored tai chi program could
improve postural stability in patients with Parkinson's disease. Because the program
emphasized rhythmic weight shifting, symmetric foot stepping, and controlled movements
near the limits of stability, we hypothesized that tai chi would be more effective in
improving postural stability in limits-of-stability tasks than a resistance-based exercise
regimen or low-impact stretching (control).
METHODS
Study Design
We designed a randomized clinical trial to compare the effects of exercise at 6 months in a
group of patients assigned to tai chi classes with the effects in groups assigned to resistance-
training or stretching classes. Each group participated in a 60-minute class that met twice
weekly for 24 weeks. An expanded description of the methods is provided in the
Supplementary Appendix, available with the full text of this article at NEJM.org. The trial
protocol, also available at NEJM.org, was approved by the institutional review board of the
Oregon Research Institute, and written informed consent was obtained from all participants.
All authors vouch for the completeness and accuracy of the data and attest to the fidelity of
the trial to the protocol.
Study Participants
Study participants were recruited from four Oregon cities (Eugene, Corvallis, Salem, and
Portland) by means of newspaper advertisements, referrals from neurologists or physical
therapists, and information distributed to local support groups for persons with Parkinson's
disease. Eligibility criteria included a clinical diagnosis of Parkinson's disease, with a
disease severity rating of stage 1 to 4 on the Hoehn and Yahr scale (which ranges from 1 to
5, with higher scores indicating more severe disease)4; an age of 40 to 85 years; at least one
score of 2 or more for at least one limb for the tremor, rigidity, postural stability, or
bradykinesia items in the motor section of the Unified Parkinson's Disease Rating Scale
(UPDRS) III)18; stable medication use; ability to stand unaided and walk with or without an
assistive device; medical clearance for participation; and willingness to be assigned to any of
the three interventions. Exclusion criteria were current participation in any other behavioral
or pharmacologic study or instructor-led exercise program, a Mini–Mental State
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examination19 score lower than 24 (indicating some degree of cognitive impairment),
debilitating conditions or vision impairment that would impede full participation in the
study, and unavailability during the study period.
Screening and Randomization
Research staff screened patients by telephone. Those who met prescreening criteria
underwent an in-person evaluation and baseline assessment. Eligible participants were
randomly assigned to one of the interventions, in a ratio of 1:1:1, without stratification, with
the use of permuted-block randomization once eligibility was confirmed and baseline
assessments were completed. Outcome assessors were unaware of group assignments.
Exercise Interventions
Tai Chi—The protocol consisted of six tai chi movements17 integrated into an eight-form
routine (see the Supplementary Appendix for more details).20,21 Because the goal was to
maintain balance through postural control, the protocol was specifically designed to tax
balance and gait by having participants perform symmetric and diagonal movements, such
as weight shifting, controlled displacement of the center of mass over the base of support,
ankle sways, and anterior–posterior and lateral stepping. The first 10 weeks emphasized the
mastery of single forms through multiple repetitions; later weeks focused on repetitions to
enhance balance and increase locomotion. Natural breathing was integrated into the training
routine.
Resistance Training—The protocol, developed from the exercise literature,11,22–25
focused on strengthening the muscles that are important for posture, balance, and gait.
Resistance (with weighted vests and ankle weights) was introduced at week 10. Weighted-
vest resistance was initially set at 1% of body weight and was increased by approximately 1
to 2% of body weight, depending on each participant's tolerance, every fifth week until 5%
of body weight was achieved. Ankle weights started at 0.45 kg (1 lb) per limb and were
gradually increased to 1.36 kg (3 lb). The routine involved 8 to 10 exercises, including
forward and side steps, squats, forward and side lunges, and heel and toe raises, performed
in 1 to 3 sets of 10 to 15 repetitions. Progression was modified for participants with physical
limitations. Natural breathing was emphasized during the training routine.
Stretching—This control condition was designed to provide a low-intensity exercise
program with the social interaction and enjoyment inherent in the two other interventions
but without similar training benefits in lower-extremity weight bearing, strength, or
balance.13,20 The core activities encompassed a variety of seated and standing stretches
involving the upper body (neck, upper back, shoulders, chest, and arms) and lower
extremities (quadriceps, ham-strings, calves, and hips), with the use of gentle joint extension
and flexion and trunk rotation. Abdominal breathing, with an emphasis on inhaling and
exhaling to maximum capacity, and relaxation of major muscles were also included.
Primary Outcomes
Primary outcomes consisted of two indicators of postural stability — maximum excursion
and directional control — as measured by computerized dynamic posturography (Balance
Master System, NeuroCom). Maximum excursion is an assessment of the limits of self-
initiated movements as patients shift or lean their center of gravity, without falling, toward
the theoretical limit (100%) in each of eight target directions. Directional control, a measure
of movement accuracy, is calculated by comparing the amount of movement toward the
target with the amount of extraneous movement. Scores on both measures range from 0 to
100%, with higher percentages indicating better balance or control.
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Secondary Outcomes
Gait (stride length and walking velocity) was quantified with the use of a computerized 4.3-
m (14 ft) walkway (GAITRite, CIR Systems). Participants were instructed to walk at their
normal pace for four trials; the results were averaged to derive a score for each measure,
with higher scores indicating better gait ability. Strength of bilateral knee extensors and
flexors was measured at an angular velocity of 60 degrees per second with the use of an
isokinetic dynamometer (Biodex System 3, Biodex Medical Systems). Summary peak
torque values (in Newton meters [Nm]) of five cycles of maximal extension and flexion
were calculated from the average of measurements of both limbs. The functional-reach
test26 assessed the maximal distance a participant could reach forward beyond arm's length
while maintaining a fixed base of support in a standing position, with higher scores
indicating better balance. The timed up-and-go test27 measured the time (in seconds) taken
to rise from a chair, walk 3.1 m (10 ft), return, and sit down, with a shorter time indicating
better mobility. Participants' motor symptoms were assessed with the 14-item UPDRS III18;
scores range from 0 to 56, with lower values indicating less motor disability. Assessors were
trained by a board-certified neurologist according to the standard protocol.28 Interrater
reliability was 0.96. Falls were monitored by means of daily “fall calendars” that were
maintained by the study participants13 and collected monthly throughout the intervention or
until a participant withdrew from the study.
Test Procedures
Outcome measures were assessed at baseline, at 3 and 6 months, and 3 months after
completion of the intervention. Participants were instructed to follow their normal schedules
for physical activity and medication during the 6-month intervention period. Assessments
were conducted during times when participants were in “on” periods (i.e., when medication
was working and symptoms were controlled). The participants' antiparkinsonian medications
were monitored by means of a self-reported measure.29
Statistical Analysis
All primary and secondary analyses were conducted on an intention-to-treat basis. Between-
group differences in demographic and baseline variables were tested with a chi-square test
for categorical variables and a one-way analysis of variance for continuous variables.
Intervention effects on primary and secondary continuous outcome measures were compared
by means of mixed repeated-measures analysis of variance, with and without adjustment for
baseline and time-varying covariates (e.g., age, sex, disease stage, health status, medication
use and change, and level of physical activity). Pairwise comparisons between the tai chi
group and the two other groups were conducted only if the omnibus F-test statistics
indicated that the null hypothesis should be rejected. Independent-sample t-tests (with 95%
confidence intervals) were used to compare group means. Paired t-tests were used to
examine within-group changes from baseline to 6 months. Negative binomial regression was
used to model data on falls and to derive incidence-rate ratios (with 95% confidence
intervals). The same analytic procedures were used to examine the sustainability of the
intervention effects.
We calculated that a sample of 45 participants per group would provide at least 80% power
to detect a between-group difference of 6 percentage points in maximum excursion and 10
percentage points in directional control from baseline to 6 months, assuming a 15% attrition
rate, at a two-tailed alpha level of 0.05. These predicted percentage-point differences equate
to a medium effect size of 0.30 or greater (the difference between two means divided by the
pooled standard deviation for the data). For the primary outcomes, a two-tailed alpha level
of 0.01 (for four corrected comparisons by the Bonferroni method) was considered to
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indicate statistical significance. Statistical analyses were performed with the use of SPSS
software, version 17 (IBM), and Stata software, version 11 (StataCorp).
RESULTS
Baseline Characteristics of the Participants
From May 2008 through November 2010, a total of 309 persons were screened for
eligibility; 195 qualified and underwent randomization (Fig. 1 in the Supplementary
Appendix). Table 1 shows the baseline characteristics of the study population. A total of 164
persons (84%) were at stage 2 or higher on the Hoehn and Yahr staging system (range, 1 to
4; median, 2.5). The groups were well matched with regard to baseline characteristics,
including age, sex, duration of Parkinson's disease, Hoehn and Yahr stages, and baseline
study outcomes of interest.
A total of 176 participants completed their assigned interventions, and 185 provided
complete data on the outcome measures at follow-up. There were no significant differences
in the baseline demographic variables or primary outcomes between participants who
completed the trial and those who did not. The average attendance across the 24-week
period was 37 sessions (77%; 37 of 48 in tai chi; 37 of 48 in resistance training; and 38 of 48
in stretching; median, 39; range, 3 to 48). A total of 137 participants (70%) attended 36 or
more sessions (75%). Attendance did not differ significantly among the groups (P = 0.67).
There were no significant within-group changes in participants' outside physical activity (P
= 0.23) or use of anti-parkinsonian medication (P = 0.16).
Primary Outcomes
Mean (±SD) between-group differences in outcomes at 6 months are shown in Table 2. The
participants in the tai chi group performed significantly better than those in the resistance-
training and stretching groups on the primary outcomes. The tai chi group had better
performance than the resistance-training group in maximum excursion, with a between-
group difference of 5.55 percentage points (95% confidence interval [CI], 1.12 to 9.97; P =
0.01), and in directional control, with a between-group difference of 10.45 percentage points
(95% CI, 3.89 to 17.00; P = 0.002). The tai chi group also had significantly better
performance than the stretching group in both maximum excursion and directional control,
with between-group differenc es of 11.98 percentage points (95% CI, 7.21 to 16.74) and
11.38 percentage points (95% CI, 5.50 to 17.27), respectively (P<0.001 for both
comparisons). The significant effect of tai chi remained after adjustment for covariates.
From baseline to 24 weeks, the participants in the tai chi group had a mean increase of 9.56
percentage points in maximum excursion and 8.02 percentage points in directional control
(P<0.001 for both outcomes). Participants in the resistance-training group had a mean
increase of 4.02 percentage points in maximum excursion (P = 0.02) but did not have a
significant change in directional control (2.43 percentage points, P = 0.35). No significant
change from baseline was observed in the stretching group.
Secondary Outcomes
Significant between-group differences were observed after 24 weeks (Table 2). The tai chi
group had significantly better performance on the measures of gait and strength, better
scores on the functional-reach and timed up-and-go tests, and better UPDRS III scores, as
compared with the stretching group (P<0.001 for all comparisons). The tai chi group also
outperformed the resistance-training group on stride length and functional reach (P = 0.01
for both comparisons).
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From baseline to 24 weeks, participants in the tai chi group had mean increases of 10.3 cm
in stride length (P<0.001), 10.4 cm per second in walking velocity (P<0.001), 13.9 Nm in
knee extension (P = 0.001), 5.1 Nm in knee flexion (P = 0.01), and 5.0 cm in functional
reach, (P<0.001), with decreases of 1.05 seconds on the up-and-go test and 6.42 points in the
UPDRS III score (with lower scores indicating improvement). Similar improvements were
observed in the resistance-training group: mean increases of 4.3 cm in stride length (P =
0.01), 10.0 cm per second in walking velocity (P = 0.001), 14.6 Nm in knee extension
(P<0.001), 8.9 Nm in knee flexion (P = 0.001), and 2.2 cm in functional reach (P = 0.007),
as well as decreases of 1.00 second on the up-and-go test and 5.07 points in the UPDRS III
score (P<0.001 for both comparisons). No significant change from baseline was observed in
the stretching group, except for deterioration in walking velocity (a decrease of 4.50 cm per
second, P = 0.01) and improvement in the UPDRS III scores (a decrease of 1.40 points, P =
0.05).
A total of 381 falls in 76 of the 195 participants (39%) were documented during the 6-month
study period (Table 3). The incidence rate of falls was lower in the tai chi group (0.22 per
participant-month) than in the other two groups. Participants in the tai chi group had 67%
fewer falls than those in the stretching group (incidence-rate ratio, 0.33; 95% CI, 0.16 to
0.71). They had marginally fewer falls than the participants in the resistance-train ing group
(incidence-rate ratio, 0.47; 95% CI, 0.21 to 1.00). All intervention effects remained
significant after adjustment for baseline and time-varying covariates.
Maintenance of Intervention Gains
Analyses at the 3-month postintervention follow-up indicated that gains in primary and
secondary outcomes in the tai chi group were maintained (Table 2 in the Supplementary
Appendix) and that, in this postintervention period, participants in the tai chi group had
fewer falls than those in the stretching group (incidence-rate ratio, 0.31; 95% CI, 0.14 to
0.67; P = 0.003) and those in the resistance-training group (incidence-rate ratio, 0.40; 95%
CI, 0.18 to 0.88; P = 0.02)
Adverse Events
No major adverse events were noted (Table 4).
DISCUSSION
We found that a program of twice-weekly tai chi for 24 weeks, as compared with a
resistance-training program or a stretching program, was effective in improving postural
stability and other functional outcomes in patients with mild-to-moderate Parkinson's
disease. Tai chi training also significantly reduced the incidence of falls, as compared with
the stretching program. Improvements in primary and secondary outcomes were maintained
3 months after the intervention, a finding that is consistent with prior research involving
adults 70 years of age or older.13 No serious adverse events were observed during tai chi
training, indicating the safety and usefulness of this intervention for persons with
Parkinson's disease.
The improvement in maximum excursion with reduced deviation in movement, as shown on
the posturographic limits-of-stability tests, suggests that tai chi training reduced dyskinesia
by increasing the ability of the participants to adopt effective sway strategies (at the ankle or
hip), engage in controlled movements with improved balance control near the limit of
stability, or both. Clinically, these changes indicate increased potential for effectively
performing daily life functions, such as reaching forward to take objects from a cabinet,
transitioning from a seated to a standing position (and from standing to seated), and walking,
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while reducing the probability of falls. Similarly, the marked increase in gait velocity in
participants in the tai chi group was associated with significant increases in stride length.
These improvements in gait characteristics support the efficacy of tai chi in alleviating the
bradykinetic movements associated with Parkinson's disease.
The tai chi protocol stresses weight shifting and ankle sway to effectively move the person's
center of gravity toward the limits of stability, alternating between a narrow stance and a
wide stance to continually change the base of support, increasing support-leg standing time
and trailing-leg swing time, engaging rotational trunk movements with upright posture, and
performing heel-to-toe (forward) and toe-to-heel (backward) stepping movements to
strengthen dorsiflexion and plantar flexion. These inherent training features may have led to
improved postural control and walking ability. Although these improvements indicate that
tai chi would be effective in enhancing neuromuscular rehabilitation, the mechanisms
behind the therapeutic change in participants' motor control and mobility remain less
understood and warrant future exploration.
Falls are a common and sometimes life-threatening event in patients with Parkinson's
disease.32,33 However, to our knowledge, no clinical trial has shown the efficacy of exercise
in reducing falls in this population. Thus, this study adds to the behavior-based treatment
literature by showing that tai chi can effectively reduce the incidence of falls in patients with
Parkinson's disease.
This study has some limitations. First, given the behavior-based treatments, participants
were aware of their intervention assignments. This awareness may have introduced biases in
the results, since persons interested in participating may have had positive expectations
about the benefits of exercise. Second, we did not include a nonexercise control group, so
the net gain of tai chi training cannot be gauged. However, the results of this trial show that
tai chi is more effective than low-intensity, low-impact exercise programs in alleviating the
symptoms of Parkinson's disease and improving functional ability. Finally, all participants
were tested during “on” periods, which may have masked underlying changes induced by
the training interventions.
In conclusion, tai chi appears to be effective as a stand-alone behavioral intervention
designed to improve postural stability and functional ability in people with Parkinson's
disease.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
Supported by a grant (NS047130) from the National Institute of Neurological Disorders and Stroke.
We thank all the study participants (in Eugene, Corvallis, Salem, and Portland) for their support and dedication to
this research project; the neurologists for providing medical clearance and Par kinson's disease stage diagnoses for
their participating patients; the project instructors (Vicki Anderson, Denise Thomas-Morrow, Don Hildenbrand,
Brian McCall, James Lusk, Nancy Nelson, Teena Hall, Machiko Shirai, and Julie Tye); the research assistants
(Debbie Blanchard, Kristen Briggs, Ruben Guzman, Daehan Kim, Lisa Marion, Arissa Fitch-Martin, Kimber
Mattox, Julia Mazur, Donna McElroy, Jordyn Smith, and Rachel Tsolinas); the physical therapists (Andrea Serdar,
Jeff Schlimgen, Jennifer Wilhelm, Ryan Rock-wood, and Connie Amos at Oregon Health and Science University);
the study data analyst, Shanshan Wang; Kathryn Madden and the members of the institutional review board at the
Oregon Research Institute for their careful scrutiny of the study protocol; and Ron Renchler for proofreading earlier
drafts of the manuscript.
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Table 1
Demographic and Clinical Characteristics of the Study Participants at Baseline.*
Characteristic Tai Chi (N = 65) Resistance (N = 65) Stretching (N = 65)
Age — yr 68±9 69±8 69±9
Female sex — no. (%) 20 (30.8) 27 (41.5) 26 (40.0)
Body-mass index28±5 27±5 27±5
Hoehn and Yahr stage — no. (%)
1–1.5 9 (13.8) 14 (21.5) 8 (12.3)
2–2.5 34 (52.3) 27 (41.5) 28 (43.1)
3 22 (33.8) 24 (36.9) 29 (44.6)
Age at initial diagnosis — yr 61±12 65±9 65±11
Duration of disease — yr 8±9 8±9 6±5
Antiparkinsonian medications taken — no.
Levodopa or carbidopa 43 50 50
Pramipexole or ropinirole 20 21 12
Other 10 16 20
Self-reported health status — no. (%)
Poor or fair 35 (53.8) 31 (47.7) 28 (43.1)
Good 23 (35.4) 28 (43.1) 29 (44.6)
Very good or excellent 7 (10.8) 6 (9.2) 8 (12.3)
Score for self-reported habitual physical activity123±67 107±54 116±62
Self-reported coexisting chronic conditions — no. (%)§
0 12 (18.5) 9 (13.8) 12 (18.5)
1 24 (36.9) 17 (26.2) 16 (24.6)
2 29 (44.6) 39 (60.0) 37 (56.9)
*Plus–minus values are means ±SD. The chi-square test was used for categorical variables, and one-way analysis of variance for continuous
variables. There were no significant between-group differences in any baseline characteristics. A more detailed listing of baseline characteristics is
available in the Supplementary Appendix.
The body-mass index is the weight in kilograms divided by the square of the height in meters.
Activity was measured by means of the Physical Activity Scale for the Elderly,30 with scores ranging from 7 to 313 (derived by multiplying
activity participation by established item weights). Higher scores indicate higher levels of habitual physical activity.
§Conditions included arthritis, heart disease, high blood pressure, lung disease, diabetes, osteoporosis, depression, chronic back pain, and cancer;
the number of conditions per participant ranged from 0 to 9.
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Table 2
Study Measures at Baseline and 6 Months and Between-Group Differences in the Change from Baseline.*
Measure Tai Chi (N = 65) Resistance (N = 65) Stretching (N = 65) Between-Group Difference in Mean Change from Baseline
Tai Chi vs. Resistance (95%
CI) P Value Tai Chi vs. Stretching (95%
CI) P Value
Maximum excursion (%)
Baseline 64.05±16.60 64.02±18.53 64.35±17.22
6 mo 73.62±13.44 68.03±18.48 61.94±16.39 5.55 (1.12 to 9.97) 0.01 11.98 (7.21 to 16.74) <0.001
Directional control (%)§
Baseline 65.75±20.16 65.12±21.60 65.93±17.23
6 mo 73.77±11.49 62.69±22.82 62.56±21.62 10.45 (3.89 to 17.00) 0.002 11.38 (5.50 to 17.27) <0.001
Stride length (cm)
Baseline 115.6±19.7 114.5±21.1 115.7±18.6
6 mo 125.9±20.3 118.8±20.7 113.6±18.5 5.9 (1.5 to 10.4) 0.01 12.3 (8.3 to 16.4) <0.001
Gait velocity (cm/sec)
Baseline 110.1±21.0 109.2±25.4 110.9±21.7
6 mo 120.6±21.5 119.1±24.0 106.4±20.2 0.5 (6.2 to 7.1) NS 14.9 (9.8 to 20.1) <0.001
Peak torque knee extension (Nm)**
Baseline 61.8±31.5 59.2±37.0 61.6±37.4
6 mo 75.7±38.7 73.8±40.5 62.1±30.8 −0.6 (−10.8 to 9.5) NS 13.5 (3.4 to 23.6) 0.01
Peak torque knee flexion (Nm)**
Baseline 32.6±19.1 29.1±17.0 32.6±18.4
6 mo 37.7±19.3 38.0±18.2 30.0±17.9 −3.8 (−10.2 to 2.7) NS 7.7 (1.9 to 13.6) 0.01
Functional reach (cm)††
Baseline 24.4±6.9 24.4±6.5 25.0±7.3
6 mo 29.4±5.5 26.6±6.5 25.0±7.3 2.8 (0.6 to 5.0) 0.01 4.9 (3.0 to 6.9) <0.001
Timed up and go (sec)‡‡
Baseline 8.60±2.90 8.95±2.72 8.69±3.18
6 mo 7.55±2.69 7.95±2.60 8.67±3.45 −0.05 (−0.55 to 0.46) NS −1.03 (−1.58 to 0.47) <0.001
UPDRS III score§§
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Measure Tai Chi (N = 65) Resistance (N = 65) Stretching (N = 65) Between-Group Difference in Mean Change from Baseline
Tai Chi vs. Resistance (95%
CI) P Value Tai Chi vs. Stretching (95%
CI) P Value
Baseline 15.28±5.59 15.32±6.04 15.06±6.17
6 mo 8.86±4.12 10.25±4.83 13.66±7.54 −1.34 (−3.28 to 0.59) NS −5.02 (−6.90 to 3.13) <0.001
*Plus-minus values are means ±SD. NS denotes not significant. A more detailed version of the table, including results from the 3-month postintervention follow-up, is available in the Supplementary
Appendix.
Mixed repeated-measures analysis of variance (group by time) with baseline, 3-month, and 6-month values indicated a significant between-group difference across all outcome measures (range, P = 0.006
to P<0.001). Analyses were performed on an intention-to-treat basis. Point estimates and estimates falling within the 95% confidence interval were generated from independent t-tests for group differences.
(See also Fig. 1 in the Supplementary Appendix.)
Maximum excursion was assessed as the farthest distance displaced by the participant's center of gravity during performance of leaning and reaching tasks. Scores range from 0 to 100%, with higher
percentages indicating better balance.
§Directional control was assessed as the amount of movement toward a target, as compared with extraneous movement (away from the target), defined as the ratio of the amount of intended movement
minus the amount of extraneous movement, divided by the amount of intended movement. The composite score of eight directions was used for analyses. Scores range from 0 to 100%, with higher
percentages indicating better movement control.
Stride length was measured as the distance between the heel points of two consecutive footprints of the same foot. Higher scores indicate greater stride length.
Gait velocity was measured by dividing the distance traveled by the ambulation time. Higher scores indicate greater gait velocity.
**Peak torque was measured at an angular velocity of 60 degrees per second. Values are given in Newton meters (Nm). Results were the average of five repetitions of measurements at both limbs, with
higher values indicating greater strength.
††Functional reach was assessed as the maximal distance a participant could reach forward beyond arm's length while maintaining a fixed base of support in a standing position. Higher scores indicate
better balance.
‡‡Timed up and go was measured as the time taken to rise from a chair, walk 3.1 m (10 ft), return, and sit down. Higher scores indicate better mobility.
§§The 14-item motor section of the Unified Parkinson's Disease Rating Scale (UPDRS) III was scored on a 5-point Likert scale from 0 to 4, with 0 representing no impairment and 4 representing marked
impairment. Lower values indicate less motor disability. A change of 5 points or more in the score is considered clinically meaningful.31
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Table 3
Self-Reported Falls during the 6-Month Intervention, According to Group.*
Falls Tai Chi (N = 65) Resistance (N = 65) Stretching (N = 65)
Total falls62 133 186
No. of falls — no. of participants (%)
Any 19 (29) 31 (48) 26 (40)
1 3 (5) 8 (12) 4 (6)
2 4 (6) 7 (11) 2 (3)
3 12 (18) 16 (25) 20 (31)
Rate — no./participant-month 0.22 0.51 0.62
*Falls were defined as unintentionally coming to rest on the floor or the ground or falling and hitting objects such as stairs or pieces of furniture.
A significant difference was found in the incidence-rate ratio between the tai chi and stretching groups (P = 0.005); a nonsignificant difference
was found between the tai chi and resistance-training groups (P = 0.05).
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Table 4
Adverse Events.
Event Tai Chi Resistance Stretching
number of events
In class*
Fall2 4 5
Muscle soreness or pain 1 4 1
Dizziness or faintness 0 3 2
Symptoms of hypotension 0 3 1
Out of class
Fall19 31 26
Symptoms of chest pain or discomfort 0 3 2
Symptoms of hypotension 0 1 2
Low back pain 4 4 5
Ankle sprain 1 2 1
*Values are the number of events that occurred during in-class sessions.
Data on falls are based on the total falls reported by participants in their “falls calendars.”
Values are the number of events that occurred outside class settings (i.e., in the home or during an assessment). Participants did not engage in
home practice; events presented are those that occurred in a home environment while participants engaged in a habitual activity (self-reported) or
that were observed during a laboratory assessment (assessor-reported).
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... At the same time, Mul_C is also a complex form of exercise, involving balance, muscle strength, cardiopulmonary exercise and flexibility training. Previous studies have showed that Mul_C significantly improves motor symptoms in PD patients, and the UPDRS III decrease (6.3-9.8 points) [37,38] exceeds the minimal clinically important difference (3.1 points) [39], and also exceeds high-intensity aerobic exercise (AE) [40], BGT [41] and Stretch [42], but less than PT and Yoga [43]. In addition, BWS_TT may be a good option for PD patients who cannot receive conventional ground gait training due to severe postural instability, orthostatic hypotension, or balance impairment [44]. ...
... The purpose is to improve the muscle strength, even in PD patients [50,51]. In addition, previous studies showed that RT was a more effective form of exercise than other exercise types (e.g., Stretch [42], Mul_C [65]) in improving muscle strength in PD patients. Notably, TC also significantly better than many other exercise types. ...
... Therefore, these provide the possibility for TC to effectively improve muscle strength in PD patients. The results of Li, Harmer, Fitzgerald, Eckstrom, Stock, Galver, Maddalozzo, Batya [42] showed that 24 weeks TC and RT had similar effects on the improvement of lower extremity muscle strength in PD patients, and were significantly better than Stretch. In summary, these are the reason why RT and TC significantly improve muscle strength compared with many other exercise types in PD patients. ...
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Background Exercises are an effective treatment in Parkinson’s disease (PD), but there is still controversy over which types should be used. We aimed to compare and rank the types of exercise that improve PD symptoms by quantifying information from randomised controlled trials. Methods We performed a systematic review and network meta-analysis and searched PubMed, MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and China National Knowledge Infrastructure (CNKI) from their inception date to June 30, 2022. We included randomized controlled trials of 24 types of exercise for the interventional treatment of adults (≥ 50 years old) with PD. Effect size measures were standardized mean differences (SMDs) with 95% credible intervals (CrIs). The confidence of evidence was examined using Confidence in Network Meta-Analysis (CINeMA). Results We identified 10 474 citations and included 250 studies involving 13 011 participants. Results of NMA showed that power training (PT) had the best benefits for motor symptoms compared with the control group (CON), with SMDs (95% CrI) (-1.46, [-2.18 to -0.74]). Body weight support treadmill training (BWS_TT) showed the best improvement in balance (1.55, [0.72 to 2.37]), gait velocity (1.15 [0.57 to 1.31]) and walking distance (1.96, [1.18 to 2.73]), and robotic assisted gait training (RA_GT) had the most benefits for freezing of gait (-1.09, [-1.80 to -0.38]). For non-motor symptoms, Dance showed the best benefits for depression (-1.71, [-2.79 to -0.73]). Only Yoga significantly reduced anxiety symptom compared with CON (-0.53, [0.96 to -0.11]). Only resistance training (RT) significantly enhanced sleep quality and cognition (-1.42, [-2.60 to -0.23]; 0.51, [0.09 to 0.94]). For muscle strength, PT showed the best advance (1.04, [0.64 to 1.44]). For concern of falling, five types of exercise were more effective than CON. Conclusions There is low quality evidence that PT, Yoga, BWS_TT, Dance, and RT are the most effective treatments, pending outcome of interest, for adults with PD. Trial registration PROSPERO (CRD42021220052).
... PD is characterized by the progressive death of dopaminergic neurons and occurs mostly in the elderly with an increasing prevalence rate (Samii et al., 2004). As of 2019, more than 5 million people worldwide suffer from PD. Patients often have motor dysfunction, such as rest tremor, stiffness, bradykinesia, and postural instability (Li et al., 2012). Nonmotor symptoms, such as underlying psychological problems and sleep disorder, aggravate the process of patients' disabilities (Boland and Stacy, 2012). ...
... However, there was no difference between any groups if all patients with PD were not on medication. Besides, two RCTs (Cheon et al., 2013;Li et al., 2012) showed that TCQ had a better improvement on UPDRS scores compared to stretching. A recent meta-analysis (Yu et al., 2021) published by Yu et.al in 2021 showed no significant difference between the TCQ group and the control group. ...
... A meta-analysis (Yu et al., 2021) Yang et al., 2015;Ni et al., 2014) showed consistent results of significant improvement in FRT in the TCQ group, and TCQ plus medication was better than other active therapies plus medication (SMD=− 0.77, 95%CI (− 1.51, − 0.03), P = 0.04). Besides, the effect of TCQ was superior to stretching and resistance training in FRT, maximum excursion, and directional control (Li et al., 2012). However, the effect of TCQ on TUGT is controversial. ...
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Background Neurodegenerative diseases have become an important concern with the accelerated aging process. Tai Chi Quan (TCQ) has positive benefits for brain health and chronic diseases. The aim of this study was to summarize the protective effects of TCQ for motor function, cognition, quality of life, and mood in patients with neurodegenerative diseases. Methods A systematic search was conducted via PubMed database and the Web of Science core collection database until August 20, 2021. The available English systematic reviews, meta-analyses, and clinical trials were included. Two reviewers completed the screening and assessment process independently. Results A total of 28 studies on Parkinson's disease, 21 on cognitive impairment, and 9 on multiple sclerosis met the included criteria. The study found that TCQ remarkably improved general motor function and balance, and prevented falls for Parkinson's disease. TCQ significantly improved global cognitive function for cognitive impairment. TCQ was likely safe and beneficial for multiple sclerosis as result of heterogeneous outcomes and small samples. Conclusion TCQ exercise can effectively improve the motor function, global cognitive function, and falls in patients with neurodegenerative diseases. However, the positive effects of TCQ on the quality of life and mood of patients with neurodegenerative diseases need further evidence.
... En años recientes se ha prestado atención a los beneficios que la práctica de TaiChí le reporta a los sujetos de la tercera edad. 28 El TaiChí es un arte marcial originado en la China medieval que prescribe la suave transición del sujeto entre figuras corporales que se corresponden con un estilo de defensa personal. La práctica del TaiChí también podría ser recomendada en el enfermo parkinsoniano como una forma de mejorar la coordinación motora, la estabilidad postural, y la marcha. ...
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La Enfermedad de Parkinson (EP) es, hasta esta fecha, una enfermedad progresiva e incurable, asistida mediante fármacos o procederes neuroquirúrgicos paliativos, producida por la degeneración de las neuronas de los ganglios basales del mesencéfalo que segregan dopamina. 1-2 La característica histopatológica predominante de la EP es la muerte progresiva de las neuronas presentes en la sustancia nigricans del cerebro, lo que origina una disfunción de la regulación de las estructuras cerebrales implicadas en el control del movimiento voluntario. No es de extrañar entonces que los movimientos involuntarios sean el síntoma clínico distintivo de la EP.
... As is known, physical activity can not only effectively regulate the blood glucose level in T2DM (15,16) but also play a positive role in increasing BMD, thus is helpful to improving balance (17,18) and reducing falls (19). Exercise is also effective in preventing chronic diseases (5). ...
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... Li and colleagues' randomized control trial was conducted over a 6-month period of time and not extrapolated to 1 year; however, additional research from Li et al did support extended benefits up to 3 months following a 24-week Tai Chi program. 27,38 Given that our study population age was over 65, the CDC recommendation would be to continue fallreducing exercise-based therapy indefinitely; however, our literature review turned up limited longitudinal studies. 4,6 Our study also utilized data on costs related specifically to falls resulting in injury. ...
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... Two pilot studies addressed the efficacy of Tai Chi in improving postural stability in PD [11,12]. A randomized controlled trial by Li et al. showed improvements in maximal excursion, direction control, gait velocity and quality of life in PD patients after 6 months of Tai Chi exercise [13]. Interestingly, a recent study reported that, after Tai Chi training, the reduced peripheral inflammation was positively related to improved Berg balance scale (BBS) scores in PD patients [14]. ...
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Background Yang-ge dancing is a culturally specific exercise in which people are required to perform motor skills in coordination with rhythmic music. As an integrated exercise with both physical (decelerating the progression of aged-related motor function degeneration) and mental benefits, it has gained great popularity in China, especially among middle-aged and older adults. It remains largely unknown whether Yang-ge dancing (YG) can effectively improve main symptoms of Parkinson’s disease (PD), while conventional exercise rehabilitation program has been recommended in the hospital setting. To this end, this study aimed to investigate the comparative effects of exercise therapy on motor function of PD patients. Materials and methods A sample of 51 PD patients were randomly assigned to Yang-ge dancing, conventional exercise, or conventional exercise with music. Participants in each group performed 60 min per session, five sessions per week of interventions for 4 weeks. All the participants were assessed using the Unified Parkinson’s Disease Rating Scale—motor examination, Berg balance test, timed up and go test, and Purdue pegboard test. Motor performances were examined before and after intervention. Results All the three groups were benefited from exercise. Compared to conventional exercise, the Yang-ge dancing and conventional exercise with music had additional positive effects in mobility with reference to baseline. In addition, compared to the two conventional exercise groups (either with/without music), the Yang-ge dancing further enhanced manual dexterity. Conclusion Exercise with rhythmic auditory stimulation optimized mobility in PD, while YG dance specifically contributed to improvement in manual dexterity. Clinical trial registeration [ https://clinicaltrials.gov/ ], identifier [ChiCTR2200061252].
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Background With aging, the cognitive function of the prefrontal cortex (PFC) declined, postural control weakened, and fall risk increased. As a mind–body exercise, regular Tai Chi practice could improve postural control and effectively prevent falls; however, underlying brain mechanisms remained unclear, which were shed light on by analyzing the effect of Tai Chi on the PFC in older adults by means of functional near-infrared spectroscopy (fNIRS). Methods 36 healthy older adults without Tai Chi experience were divided randomly into Tai Chi group and Control group. The experiment was conducted four times per week for 16 weeks; 27 participants remained and completed the experiment. Negotiating obstacle task (NOT) and negotiating obstacle with cognitive task (NOCT) were performed pre- and post-intervention, and Brodmann area 10 (BA10) was detected using fNIRS for hemodynamic response. A three-dimensional motion capture system measured walking speed. Results After intervention in the Tai Chi group under NOCT, the HbO 2 concentration change value (ΔHbO 2 ) in BA10 was significantly greater (right BA10: p = 0.002, left BA10: p = 0.001), walking speed was significantly faster ( p = 0.040), and dual-task cost was significantly lower than pre-intervention ( p = 0.047). ΔHbO 2 in BA10 under NOCT was negatively correlated with dual-task cost (right BA10: r = −0.443, p = 0.021, left BA10: r = −0.448, p = 0.019). There were strong negative correlations between ΔHbO 2 and ΔHbR under NOCT either pre-intervention (left PFC r = −0.841, p < 0.001; right PFC r = −0.795, p < 0.001) or post-intervention (left PFC r = −0.842, p < 0.001; right PFC r = −0.744, p < 0.001). Conclusion Tai Chi practice might increase the cognitive resources in older adults through the PFC bilateral activation to prioritize gait performance during negotiating obstacles under a dual-task condition.
Article
Introduction: The aim of this study was to systematically explore progressive resistance training (PRT) effects in Parkinson's disease (PD). Methods: Eligible literature was systematically searched from five electronic databases (PubMed, Web of Science, Ovid, Wanfang, and China National Knowledge Infrastructure) from their inception to February 2022. Included studies were selected based on strict eligibility criteria. RevMan 5.3 software was used for statistical analysis. Results: A total of 14 studies with 761 PD patients were selected for eligibility in this systematic review and meta-analysis. A total of 383 performed trunk or upper or lower extremity PRT and 378 underwent balance training, modified fitness counts, or did not change their lifestyle. The results demonstrated positive PRT effect on freezing of gait (standardized mean difference [SMD] = -0.55, 95% CI = -0.95 to -0.16, p = 0.006), muscular strength (SMD = 1.9, 95% CI = 0.55-3.24, p = 0.006), and quality of life (SMD = -0.86, 95% CI = -1.66 to -0.06, p = 0.04) in adults with PD compared with other training programmes but not for gait velocity, stride length, timed up and go test, and Berg Balance Scale. Conclusions: This meta-analysis revealed that PRT had positive effects on freezing of gait, muscle strength, and improved quality of life during rehabilitation in PD patients.
Article
Purpose of review: Parkinson disease (PD) is a common neurodegenerative movement disorder, the prevalence of which is rising as the world population ages. It may present with motor and nonmotor symptoms, and symptomatic treatment significantly improves quality of life. This article provides an overview of the workup and differential diagnosis for PD and reviews genetic and environmental risk factors and current treatments. Recent findings: Novel treatments for the motor (eg, fluctuations and off times) and nonmotor (eg, hallucinations and orthostatic hypotension) complications of PD have been approved in recent years. In addition, with recent advances in our understanding of the genetics of PD, significant research is focusing on identifying at-risk populations and introducing genetically targeted interventions (precision medicine). Summary: PD is a heterogeneous neurodegenerative movement disorder. Affected individuals may receive substantial symptomatic relief from nonpharmacologic, pharmacologic, and surgical interventions. Although no intervention to modify the progression of PD is currently available, precision medicine and modulation of the immune system are a major focus of ongoing research.
Book
This practical, clinical reference from the two leading movement disorder experts focuses on the problems of diagnosing and managing all movement disorders. It features descriptions of the disorders, rating scales for clinical research, neurochemistry, clinical pharmacology, genetics, clinical trials, and experimental therapeutics. An accompanying 2-hour videotape contains several hundred video clips with narration that illustrates the manifestations of various movement disorders and their differential diagnoses. Uses a reader-friendly format, with diagrams, photographs, and tables, to make reference quick and easy. Includes a CD-ROM containing several hundred video clips with voice narration, keyed to the text, to help you diagnose movement disorders. Gives you just the information you need for the clinical approach to diagnosis and management, with minimal emphasis on basic science. © 2007 Stanley Fahn and Joseph Jankovic Published by null All rights reserved.
Book
This succinct volume offers an up-to-date review and comparison of the treatment options available for Parkinson's disease, and provides evidence-based recommendations on appropriate treatments for specific cases. Offers expert guidance on the best treatment options from authorities in the field. Delivers expert guidance on drug therapies, physical therapies, and surgical interventions. Discusses conditions such as depression · hallucinations · cognition · and sleep disorders. Explores neuroprotection in Parkinson's disease. Provides insights into future therapies.
Article
The clinical diagnosis of Parkinson disease (PD) is based on the identification of some combination of the cardinal motor signs of bradykinesia, rigidity, tremor, and postural instability, but few attempts have been made to develop explicit diagnostic criteria. We propose a clinical diagnostic classification based on a comprehensive review of the literature regarding the sensitivity and specificity of the characteristic clinical features of PD. Three levels of diagnostic confidence are differentiated: Definite, Probable, and Possible. The diagnoses of Possible and Probable PD are based on clinical criteria alone. Neuropathologic confirmation is required for the diagnosis of Definite PD in patients with the clinical diagnosis of Possible or Probable PD. Criteria for histopathologic confirmation of PD are also presented.